We probably all know plenty of horror stories about inpatient psychiatric facilities, ranging from the unfair to the outright abusive. Personally, I'm one of several people I know who has decided that we want to work in a hospital (either a psych ward or a specialist hospital) after seeing how shitty they are. So people can generally agree on what needs changing, but what do you think it should be changed to? In your opinion, what would be the most useful, safe, respectful and compassionate environment for inpatient psychiatric care? What should hospitals do to respect the patient's autonomy without compromising their safety? What would your ideal ward, hospital, or residential treatment centre look like? Areas to consider: daily schedules - how structured should they be? amount & type of therapy safety measures to prevent patients from harming themselves and/or others eating disorder treatment (if you have or have had an ED then you'll probably be uncomfortably familiar with the contradictory goals of "not letting you die" versus"not violating your autonomy" visitors the "burrito test" (edit: link) Weigh in!
daily schedules - select activities, based on the person. maybe meals are expected to be done in a certain room, and each day you have maybe on or two thing that you can go to for fun/helping stuff, and one or maybe two where you have to do this thing amount & type of therapy - really depends on the person. though id say maybe 1 meet a day at least, and emergency i need to talk to you visits when needed safety measures to prevent patients from harming themselves and/or others - no dangerous items can stay with patients with these problems, though if they start recovering slowly working them into being used while supervised, things like that. patients who dont have self/other harming tendancies and dont room with someone who does should be allowed to keep their things, if something becomes a problem, it goes back to only while supervised eating disorder treatment (if you have or have had an ED then you'll probably be uncomfortably familiar with the contradictory goals of "not letting you die" versus"not violating your autonomy" - ED patients are even more expected to be at meals, but if a patient doesnt come for the meal it gets brought to them by a staff memeber, preferably one they like/get along with. coming for meals are their voluntary choice, at meals probably need to eat a minimum of food, unless feeling really sick by overeatingness. people getting reintroduced to eating would start with less required food due to reprogramming their stomachs to deal with it and not just throw it up, if they had a relapse while there they would probably be expected to eat much more than when they first came, because it would have been only a few days ago they were eating decently ish visitors - chosen by the patient if or when they want visitors the "burrito test" - ??? just my thoughts, though i dont have self harm or ED experience, so im probably not the best to ask about that
- visitors - believe people when they say 'don't let this person visit'; let nonfamily people visit both because friends can be your biggest and sometimes only support and also because 'lel your unmarried partner can't visit you' is awful and often homophobic and always awful - additionally, let people contact friends via electronics if they need do, definitely let people have their fucking music. When I was considering psych ward stuff, not being able to contact friends was one of the big reasons I figured it would be actively unhelpful, since having friends who were willing to talk to me was pretty much the only thing keeping me alive, and removing that would have been counterproductive. I imagine there are a lot of people in the same situations. - choosing type of therapy would be useful, yeah. CBT is not a panacea and nor is talk-counselling, etc. As a corollary to that: educate your patients on what type of therapy does what, let them try different types and see what will help most. - ed stuff: honestly one of my biggest comments here would be that it needs to be tailored to the individual person and their individual issues. If someone can't eat with people but is more okay eating alone, work with that; if someone else does better eating six snacks a day than three meals, work with that, and so on. And listen to what people are telling you and address that: if someone's using an ED as a form of self-harm, talking about how you don't need control isn't going to help as much, and vice versa. ALSO if someone has sensory issues or dietary requirements, work with those and accept them. - Also for EDs: joined-up care with physical doctors for the issues therein. Get people checked for nutrient deficiencies, anaemia, metabolic or thyroid fuckery, and get those treated. Get physiotherapy and/or rheumatologists in to help deal with musculoskeletal damage. Don't just leave that for years later so your patients will get fucked up further. - I think the burrito test depends on what sort of care you're in; if it's emergency short-term care, equivalent to 'oh shit my appendix just ruptured', that's very different from long-term residential care (in which case you absolutely need agency). However, I think it's necessary to give more agency as much as you can, because so much of mental health bullshit is about having your agency removed, and anything that upholds that is going to hurt, and anything that challenges that will probably help. - super structured schedules are going to be hell on anyone with sleep disorders, which given the demographic is 'pretty much everyone, let's not bullshit'. I'm not sure how you'd fix that but I think it needs taken into account, especially given how important sleep is for recovery or acting vaguely functional. - better oversight of staff. Zero tolerance of people being super ableist at you. Therapists you don't have to lie to.
So, I´ve never been in an inpatient facility. I have a huge fear of them, and also rational reasons to suspect they would do me more harm than good. Take input with grain of salt. Schedules: A big reason for both irrational nope and due to said nope, rational thinking this is bad, is the loss of autonomy that comes from having someone else plan my day for me. Since Dist mentioned free time to have bad thoughts can be bad, maybe there should be an opt in/out schedule. (Outside of doctors/therapy appointments obviously.) I have the worlds weirdest sleep schedule naturally, and suspect being forced to be typically diurnal in school may have contributed to my stress. Gonna skip the next two, one I don´t trust myself to be rational about and the other I have no experience relevant to. As for visitors, would echo above that patient should be allowed to see anyone they choose who is not a danger to them or others.
@Imoyram this post explains the burrito test & its significance relatively well. I have some trouble phrasing it.
Mmm. I've also never been in an inpatient facility due to terror. Specifically, when I was in college, I desperately needed to be in inpatient treatment. But I have PTSD related to hospital settings, and an "institutional-feeling" setting would have sent me into paralyzing panic attacks for months. I don't know if there are any good options for that, or if that's enough of an edge case that it's not worth general consideration. :\
Um excuse you what if they try to have a pillowfight. That would be AGGRESSION. Yeah, man, inpatient treatment that's pillowfort party forever sounds... really comforting.
A thought on having issues with institutional settings, I wonder if it would be feasible to make inpatient treatment places well, less institutional. Have more pillows be a thing, generally try to make the environment soothing and comforting rather than clinical. This is probably a funding issue, I realize.
daily schedules - imo, daily schedules are pretty important, but I think there should be some level of autonomy and choice within it. for instance, getting to pick what groups you want to do, like having an art group and a reading group happening at the same time and you choose which one you want to go to. I think that having group therapy is a pretty good idea as well, and my opinion on therapy and going is: you can opt out of going, but you have to find something else productive to do during that time, like art or reading a book or something, you can't just sit on your bed and sleep or pick at your nails. meals are held at a certain time, and can be eaten in your room with the door open or at the tables provided for mealtimes, and you get to order off a pre-picked menu (i.e. the options on the menu are 'brussel sprouts'/'broccoli'/'mashed potatoes' and you pick what you want of those three, and then you receive that thing the next day for your meal). overall, though, I think having a daily schedule and set things that you do at set times is really, really important for recovery. if you're doing nothing all day, you're sleeping or thinking bad thoughts all day, and that's not getting better. there should, however, be some kind of free time later in the day, where you can go to your room and take a nap or have some quiet time or text friends or watch TV on the TV in the ward. there should also be planned outside/exercise time--if you aren't allowed to go outside, you should at least get some kind of exercise, and if you can go outside, you should be allowed to like, walk around and play within view of an attendant. amount & type of therapy - I think there should be at least one group therapy thing per day, with a specific theme to it that y'all are talking about that day, like parents or suicidal thoughts and getting through them (topic should be chosen by patients), and then I think there should be at least one individual therapy meeting per day, which should last at least an hour, and be more intensive and about you and your problems specifically, and it should preferably with a therapist you like--if you don't get along with the first one, you get to ask for a different one, and hopefully they're a better fit. ideally, you say what issues you have when you come in, and are then matched to a therapist who's well-equipped to handle those issues. beyond that, I think there should be specific therapeutic groups which are optional, and are geared towards more specific problems like bpd, so if you have a bpd diagnosis, you are invited to go to bpd group, which is maybe one hour per day and meets around noon after lunch, or something like that. these are purely optional, but if you go you give up, say, free time or an activity time, and you can only have one optional group in your schedule each day, so that your day isn't just all therapy. group therapy is optional, but if you choose not to go you have to be doing something productive like reading or art. safety measures to prevent patients from harming themselves and/or others - I think this is tricky, because certain things reach the point of unreasonable and yet I see where they come from. for instance, not being allowed staples seems pretty stupid, yet I know a girl who hurt herself by working at her wrist with a staple for an hour in her room with the door closed. I think that the way to prevent things like that is to allow patients to be in their room, even with the door closed, but have them be checked on every ten or fifteen minutes to make sure they're okay. not even "hi how you doing" just open the door and shut it again. I also think that certain things should be allowed--like, for instance, if a string is attached to the inside of pajama pants, leave it alone. it's unlikely to hurt anyone when it's stuck inside a pair of pants. crayons and non-sharp objects are fine to have in your room with the door closed, as are pens and pencils, but sharp objects like scissors or a shaver can only be used in view of an attendant. so if you wanted to shave your underarms, yes, you would have to do that with an attendant probably outside the door, knocking every few minutes and checking that you're okay, and if they don't get a response they can open the door and check in on you that way. and certain things just aren't allowed, like straight-up razor blades, or fishing wire (don't ask, but I wouldn't allow fishing wire in a ward). I think there's always going to be some risk of someone hurting themselves or someone else and I think it's impossible to totally prevent that, but there are ways to lessen the risk while allowing patients their autonomy. eating disorder treatment - I think eating disorder patients should be expected to show up to meals, or at least have their food brought to them in their room, where they can eat it with the door open. people likely to throw up the food on purpose shouldn't be allowed in the bathroom for an hour post-meal, and all pills are monitored by staff, so that you can't sneak in and take laxatives or something like that. people who restrict should be allowed to start on smaller meals, maybe even drinkable supplements, and then work up to regular-sized meals. I also think these people should have treatment plans that specifically include some kind of therapy and exercise plan to help them manage their eating disorder--if they don't exercise at all, they should start, and if they exercise too much, it should be restricted to a certain set of things for certain amounts of time at first, and then as they get better they can choose what they want to do when, and start picking their exercise plan themselves. visitors - friends and family can visit, but if you say you don't want to see someone, that should be respected, even if it's your parents. anyone can stop by, but you can turn them away without even talking to them, basically, and there should be a list of people who you give on arrival who are not, under any circumstances, allowed to visit, even to be turned away. the "burrito test" - I think patients should be allowed to get up and microwave a burrito in the middle of the night if they want to, or at least have a staff member do it for them. period, end of story.
And this really cool and weird idea I have every time I have to go to a hospital and they treat me like a suicide risk (last time was for a skin infection!) just because I am "not normal". Treat each patient as an individual, setting the boundaries and controls according to the patient's needs instead of a book of rules. Nah, that's silly.
I don't know how it is everywhere, but I know that in my state mental hospitals have enough funding to make things less clinical, and I know this because I've been there before and the mental hospital is less clinical, more pillows and soft chairs. I don't know about funding for the general hospital but their mental health wing was very freaking clinical. then again, they were generally worse overall. so.
There should be more focus on meeting people's dietary needs, like I've heard people say they had trouble being vegetarian in the hospital, so being vegan/having food allergies/religious food restrictions/etc etc must be even harder, and it shouldn't be
I was vegan the first time I went into the hospital, and also gluten-free. I had to pick through food to try and find stuff I could eat most of the time; the rest of the time I got a salad for every meal.
sorry this is long and a little messy. i've been in inpatient twice (each one in a different state) and while it wasn't the best i think i lucked out a lot more than other people did. they were both short term stays (just the routine "get you on a medication, make sure you aren't allergic, and teach you how to keep up with it") in adult wards, neither of which were the severe cases side of the building. the first time in oklahoma was the worst of the two, and was like this: daily schedules: there was one "how are you doing" group in the morning where you had to pick an emotion off the emotions chart. it was stupid. everything else (meals, rec, showers, meds) was a very strict schedule, and if you didn't go (aside from meds) you didn't get what each entailed. i was there eight days and saw a doctor twice, once checking in and once when i wanted to leave. AaToT: there were optional groups, but they mostly were like, aa meetings except drugs too. there was a therapist assigned to rec, a tech in the day room, and your doctor who you did not see often. safety measures: they were a little easiy going depending on what you were there for. some people were allowed to do their own laundry, others weren't even allowed out of their rooms without strict supervision next two aren't applicable b/c i don't have an ED and i had no visitors b/c i was in oklahoma alone. burrito test: definitely not. my second stay in texas was much "nicer", and closer to what i think this type of stay should be like: daily schedules: there were tons! each day of the week there were specific groups at specific times, and rec swapped from inside and outside depending on what you did the day before. each was optional but whether you did them or not (and what you did in them) counted towards your "team"'s doctor deciding if you need RTC or not. AaToT: there were spiritual groups, rec groups (different from regular rec), behavioral groups, and i forget what the last one was. they tended to talk about similar things but on different days and in very different ways. it was super neat because everyone supported each other and the leaders were never condescending or rude. they talked about things like dealing with emotions, CBT, and the importance of choices. it was a very healthy environment and even spiritual group wasn't just "only christianity is good and you are going to hell if you did/are so and so". they were very open to everyone sharing their own religions/ lack of. they were also amazing about hooking you up with aftercare/outpatient. they were like, "it is definitely not going to be our fault if you get out there and don't follow up. here's an appointment, they take your healthcare (and will even take you if you don't have any), some counties even have programs that will give you a ride if you need it. you have absolutely no excuse not to take your meds. DON'T COME BACK". safety measures: there were a lot of weird ones, but most came from past cases. if you've ever been in inpatient i'm sure you know all the crazy shit people try to kill themselves with. they also kept all toiletries/sets of scrubs locked up and you had to ask for them. the only time this rule was broken was when some of the lazier, more assholeish techs were all on shift together, and a patient immediately walked up to the drawer and stuck a toothbrush into the laundry detergent and began brushing their teeth with it. that was human error though, not hospital rules not covering something. human error was actually a little common with the tech because most of them there didn't give a shit, they were essentially being payed to sit around. except larry. he was awesome. they also seperated boys and girls by hallway, which went a long way into making me feel safer. that's just a personal thing though. again, i don't have an ED but the few people i did know there were monitored, and a lot of people had very specific dietary plans. our wing was allowed to go to a cafeteria and one of the women i was friends with they were very particular to make sure didn't give away all her food, or if she didn't eat one meal make sure she had some the next one, but respected her boundaries and didn't make her eat or isolate her or anything. visitors: my mom and sister visited once, and they had to bring an ID and have called ahead and could only come at very specific hours, you were taken to the cafeteria where others were meeting if they had scheduled visits too. they were very strict about phonecalls, if someone called in looking for someone they would not confirm or deny the person was there, and if you wanted to actually talk to a person you had to sign a permission thing and write who was allowed to talk to you. i have trouble with auditory processing with phonecalls, so i didn't use them much, but those who did had to call out first and give the callee a code i f they wanted to call back and talk again. they made VERY sure anyone who a patient didn't want knowing they were there did NOT know, at least from them. burrito test: no, but again this wasn't an RTC. things i'd change/like different? if they were a little more careful in hiring techs. a lot of them did not care at all and were rude or homophobic/transphobic, or wouldn't do things for you (e.g. if someone needed toothpaste they'd say "in a minute" and continue playing cards with their friends for another hour). and if the actual doctors would see you more. i know that one's a little impossible due to the sheer number of other cases these people have, it'd just be nice if the people in charge of giving medications were a little more involved in seeing why i might need them. i also know from knowing lots of minors who've been to inpatient (Disclamer: all experiences are local to me so it might be radically different somewhere else. i am not the end all be all example of minors inpatient. please take care of yourselves and don't ignore it if you need to go to the hospital): inpatient is absolute hell if you're a minor. doctors nurses, and techs respect/listen to your opinions and needs a LOT less than if you're an adult. they put the kids who are there for literally stabbing and killing several people and want to kill more in the same section as the kids who are just there for depression. there is a lot less "healthy environment to get better" and a lot more "oh fuck what do we do with these children". i've heard tons and tons of horror stories. inpatient for minors needs a lot of work. also this. like god damn, where the fuck are all the pillows and blankets going? i think hospitals in general are just really terrible in figuring out how many blankets and pillows it needs, because non mental health related stays are like this too, from what i've seen. TL;DR if you wanna work in this line of work, it goes a hell of a long way if you'll treat me like a human being and don't be an ass. that's really my biggest request.
the pillows in oklahoma were literally made of like, tarp with stuffing in it. you almost didn't want to ask for more because they were so horrible. i'm assuming they were like that for easier removal of... stuff. just in case.
wow, the pillows we had at my under-18 ward were actually nice. also, I maintain that patients should be allowed to shower whenever they want. they don't want to go to a group, they want to shower instead? totally fine. also I feel like they should have some say over their sleep schedule, at least by like "okay well you can go to bed now or in an hour" and "you can get up now or in an hour" and while waiting for others to get up there could be free time for other patients who are already awake, maybe? and if you don't want to go to bed when everyone else does you can be given a mini DVD player and watch a movie in your room.
I've never been an inpatient and never been likely to be, but "give people control over their sleep schedules" is something I would definitely vote for. Even after my depression mostly faded, my entire life improved drastically when I wasn't starting work at 8AM. Somebody whose internal clock is calibrated like mine to wake up around 10-ish would have big problems in a ward that made everyone get up at the same time.
in the ward I was in at under-18 they made you get up at 8 every morning. in the adult ward, you were woken up at 9 for morning meds, which took like ten seconds, and then you could just go back to sleep. all I ever did in the adult ward was sleep.
the rooms in my texas stay had showers in them (albeit they were just a button on the wall that made water come out, and there was no temp control, and if you didn't take the tp out first it would get soaked with everything else and it was on a timer) and you could indeed choose to shower instead of go to group. there wasn't a set bedtime either but you did have to stay in your room until a certain point or sit in the laundry alcove and read or color all night if you wanted. once you were in the alcove you had to stay there though. they were less about making you sleep and more about you not being disruptive to others who want to sleep. techs would monitor this though (not inside the showers, just that you were taking a lot). if you were doing nothing but taking showers all day, or not sleeping for days and days at a time, that's obviously a little worrying. edit: i will say the way they did this was both good and bad. you had to get a doctor's order for a whole lot of stuff. want to shave? need a doctor's order. want double portions at dinner because the preset meals are based on a caloric intake that doesn't work for your height/weight? doctor's order. want be allowed a cup of laundry soap? doctor's order. need special soap because the ones they give you that suck but you could never harm yourself with are irritating your skin? doctor's order. it was almost like a points system thing and it worked pretty great except for the huge amount of work it caused for the employees.
